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3.9.3.10 Nursing Addendum to Plan of Care (CCP) Form
The Nursing Addendum to Plan of Care (CCP) Form addresses PDN eligibility criteria, nursing care plan summary, health history summary, 24-hour schedule, and the rationale for the hours of PDN requested.
The following is a description of the nursing care plan summary:
• The nursing care summary is not a complete nursing care plan.
•Information must be client-focused and detailed.
•The Problem List must reflect the reasons that nursing services are needed. The problem list is not the nursing care plan. Providers should identify two-to-four current priority problems from their nursing care plan. The problem does not need to be stated as a nursing diagnosis. The problems listed should focus on the primary reasons that a licensed nurse is required to care for the client. Other attached documents are not accepted in lieu of this section.
•The Goals should relate directly to the problems listed and be client-specific and measurable. Goals may be short- or long-term; however, for many clients who receive PDN, the goals generally are long-term.
•The Outcomes are the effects of the provider's nursing interventions and must be measurable. Generally, these are more short-term than goals. For initial requests, list expected outcomes. Extension requests should note the results of nursing interventions.
•The Progress should be viewed as a "yardstick" or continuum on which progress toward goals is marked. Initial requests should state expected progress for the authorization period. Extension requests should list the progress noted during the previous authorization period. It is recognized that all progress may not be positive.
•The addendum must summarize the client's health problems relating to the medical necessity for PDN.
•The addendum must clearly communicate a picture of the client's overall condition and nursing care needs.
•The summary of recent health history is imperative in determining whether the client's condition is stable or if new nursing care needs have been identified. This section gives the PDN provider an opportunity to describe the client's recent health problems, including acute episodes of illness, hospitalizations, injuries, etc. The summary should create a complete picture of the client's condition and nursing care needs. The summary may cover the previous 90 days, even though the authorization period is 60 days; however, the objective of the summary is to capture the client's recent health problems and current health priorities. This section should not be merely a list of events. This section is the place to indicate the frequency of nursing interventions if they are different from the physician's order on the POC, such as, the order may be for a procedure to be PRN (Pro Re Nata-"As Needed"), but it is actually being performed every 2 hours.
•The addendum must include the rationale for increasing, decreasing, or maintaining the level of PDN and must relate to the client's health problems and goals.
•The addendum must include the provider's plan to decrease hours or discharge from service (if appropriate).
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